[Development and implementation of clinical pathways for acute drug toxicity].
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Acute Disease↗
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Joint primary-secondary care design of PEG care pathways.
The use of PEG feeding has increased over the past decade. This article describes the development of a care pathway to support patients and maintain standards of care in PEG feeding.
Aftercare↗
Evidence-based practice needs evidence-based implementation.
Clinical pathways have been designed to provide an effective interface between evidence and practice in healthcare. Strong evidence supports the assertion that when clinical pathways are utilized they improve outcomes. However, published evidence measuring the uptake of clinical pathways by health professionals remains sparse. This article presents a study evaluating the degree of documented compliance with the clinical pathway chart used for patients diagnosed with an acute myocardial infarction (AMI) in a major Australian regional hospital. The relationships between compliance and demographic and illness were also examined. Data were collected from 124 records with the result that the level of documented compliance was 16.5%. Clients with private health insurance had significantly higher documented compliance with the clinical pathway than those with no private health insurance. There were also significant variations in documented compliance according to the type of AMI recorded. Recommendations to improve compliance with clinical pathways are included along with recommendations for future research.
Adult↗
Establishing a proper perspective on clinical pathways before implementing a clinical improvement program.
The presumed stellar characteristics of clinical pathways have grown in unearthly proportions to the extent that our expectations of pathway utilization are unrealistic and unfounded. Therefore, before expectations go unmet and dissatisfaction with clinical pathway outcomes becomes prevalent, we must objectively analyze the clinical pathway phenomenon and understand the origins, elements, and purpose of this clinical improvement technique.
Critical Pathways↗
Secondary mutation maintains the transformed state in BaF3 cells with inducible BCR/ABL expression.
The BCR/ABL gene product of the Philadelphia (Ph) chromosome induces chronic myelogenous leukemia (CML). We generated a hematopoietic cell line, TonB210.1, with tetracycline-dependent BCR/ABL expression to investigate the pathways by which BCR/ABL transforms cells. TonB210.1 demonstrates conditional growth factor independence in tissue culture and rapidly forms tumors in mice fed the tetracycline analog doxycycline. The tumors regress completely upon doxycycline withdrawal, but ultimately reform in all animals. After a long latency, tumors also develop in animals never exposed to doxycycline. Subclones of TonB210.1 established from doxycycline-independent tumors demonstrate distinct mechanisms of transformation. Most subclones manifest increased basal levels of BCR/ABL expression; some have lost the capacity to augment expression upon induction, whereas others remain inducible. More interestingly, some subclones maintain tight conditional expression of BCR/ABL and are therefore transformed by secondary mechanisms that no longer require BCR/ABL expression. These subclones show constitutive phosphorylation of the STAT5 protein, suggesting that activating mutations have occurred upstream in the signaling pathway to STAT5. The tight conditional expression of BCR/ABL in the TonB210.1 cell line affords the opportunity to study several interesting aspects of the biology of BCR/ABL, including activation of critical signaling pathways and transcriptional programs, and its potential role in genomic instability.
Animals↗
Building clinical pathways.
TQM principles change the work environment so that point-of-service personnel can improve health care delivery to patients. The clinical pathway process starts with the principles of TQM. In the era of managed care, health care resources can be managed effectively using a clinical pathway. The multidisciplinary team has the opportunity to improve the health care services provided to patients.
Communication↗
Stroke teams and acute stroke pathways: one emergency department's two-year experience.
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Acute Disease↗
Mast cells and nitric oxide: control of production, mechanisms of response.
Mast cells are involved in numerous activities ranging from control of the vasculature, to tissue injury and repair, allergic inflammation and host defences. They synthesize and secrete a variety of mediators, activating and modulating the functions of nearby cells and initiating complex physiological changes. Interestingly, NO produced by mast cells and/or other cells in the microenvironment appears to regulate these diverse roles. This review outlines some of the pathways central to the production of NO by mast cells and identifies many of the tightly controlled regulatory mechanisms involved. Several cofactors and regulatory elements are involved in NO production, and these act at transcriptional and post-translational sites. Their involvement in NO production will be outlined and the possibility that these pathways are critically important in mast cell functions will be discussed. The effects of NO on mast cell functions such as adhesion, activation and mediator secretion will be examined with a focus on molecular mechanisms by which NO modifies intracellular signalling pathways dependent or independent of cGMP and soluble guanylate cyclase. The possibility that NO regulates mast cell function through effects on selected ion channels will be discussed. Metabolic products of NO including peroxynitrite and other reactive species may be the critical elements that affect the actions of NO on mast cell functions. Further understanding of the actions of NO on mast cell activities may uncover novel strategies to modulate inflammatory conditions.
Animals↗
Clinical pathways in home nutrition support.
In home-care settings, physicians with various medical specialties may order home enteral and/or parenteral nutrition support. Clinical pathways may be used to provide a clear, concise, standardized method for ordering and monitoring home nutrition support. The clinical pathways should be appropriate for 80% of the patients placed on the pathways, allowing for a 20% variance, or deviation, from the pathway. In one home-care facility, disease-specific clinical pathways have been used for longer than 1 year for patients with a variety of diseases requiring home nutrition support. To determine the usefulness of the home nutrition support clinical pathways, data obtained from 20 patients were analyzed. Patients were followed up while being treated using home nutrition support clinical pathways designed for oncology (9 patients), human immunodeficiency virus/acquired immunodeficiency syndrome (2 patients), short bowel syndrome (6 patients), and hyperemesis (3 patients) for 191 weeks. Overall, an average variance (deviation from the pathway) of 22% (the number of variances divided by the total weeks of therapy) was observed. The use of the pathways to provide enteral or parenteral nutrition facilitated more cost-effective care by following pathway guidelines for obtaining laboratory values and patient visits. Communication between the home-care staff and the physician was also improved. Clinical pathways can enable standardization of care for patients receiving nutrition support at home.
Critical Pathways↗
Development and implementation of evidence-based guidelines: a multisite demonstration project.
The development of alternative patient care delivery systems is being explored by health care providers, managed care corporations, insurance companies, and the government. Pathways, guidelines, care maps, and algorithms are techniques that assist in the development of patient care delivery systems with the potential to both decrease cost and ensure quality. This article reviews our experience with a program designed to transport clinical guidelines and pathways developed from evidence-based scientific knowledge to 7 acute care facilities located throughout the United States.
Critical Pathways↗
Postnatal care in hospitals: ritual, routine or individualized.
Postnatal care in hospital continues to include routine recording of observations of temperature, pulse, blood pressure, fundal height, lochia and perineal injury on clinical pathways that allow little if any leeway for individualizing care. This paper discusses the issues of designing a new clinical pathway that encompasses best practice, is woman friendly and allows for individualized care rather than routine rituals.
Critical Pathways↗
Use of an integrated care pathway: a third round audit of the management of shoulder pain in neurological conditions.
OBJECTIVES: To complete a third round audit of management of shoulder pain using an integrated care pathway, to evaluate pro forma documentation and to determine outcome. SUBJECTS AND SETTING: Thirty-four patients with upper limb paresis admitted to a rehabilitation unit during a 22-month period had shoulder pain and were included in the integrated care pathway. METHODS: Retrospective review of pro forma documentation against pre-determined standards. RESULTS: Compared with the second round audit, performance against 5 out of 9 standards for initial assessment and documentation had improved, and ranged from 56% to 94%. Achievement of 9 further standards relating to continued management ranged from 44% to 97%. Variance was not always well recorded. Shoulder pain resolved or improved in 18/34 (53%) of patients. CONCLUSION: Introducing the pro forma improved standards of documentation and demonstrated a positive outcome in over half the patients. Some problems with developing and maintaining integrated care pathways in the context of rehabilitation are discussed.
Adult↗
Implementation of a clinical pathway in management of the postoperative vestibular schwannoma patient.
OBJECTIVE: The purpose of the study was to evaluate the effectiveness of a new clinical pathway in management of patients with postoperative vestibular schwannoma. The impact on duration of hospitalization and quality of care was evaluated. STUDY DESIGN: The study was a retrospective review of 59 consecutive patients undergoing surgical intervention for vestibular schwannoma between January 1995 and July 1999. METHODS: A new clinical pathway for management of postoperative vestibular schwannoma patients was implemented at The California Ear Institute at Stanford (Palo Alto, CA) in January 1995. All patients undergoing surgical intervention subsequent to initiation of the pathway were included in the study. Data including surgical approach, patient age, sex, and tumor size were included. Duration of hospitalization and postoperative complications were recorded. During the same time period, data for patients undergoing radiation therapy for vestibular schwannomas were evaluated for length of hospital stay and in-hospital complications. Data were compared with norms recorded in the literature for duration of hospitalization and complications following surgical intervention. RESULTS: Fifty-nine patients underwent 35 middle fossa approaches and 24 translabyrinthine approaches to their tumors. The average patient age was 53 years; there were 34 female and 25 male patients. The average length of hospital stay was 3.83 days (SD = 1.4 days) with a range from 2 to 10 days. Postoperative complications were observed in 19% of patients, including eight (13%) cerebrospinal fluid (CSF) leaks, two requiring lumbar drains (3.4%); one hematoma (1.6%), one postoperative fever (1.6%), and one dural tear with associated hyponatremia (1.6%). These results compared favorably with previously recorded average hospital stays of 5.95 to 9.5 days 1,5-7 and CSF leak complication rates of 7% to 15%.9,10 CONCLUSIONS: Implementation of a clinical pathway for management of the patient with postoperative vestibular schwannoma improves efficiency of patient care, allowing decreased duration of hospitalization. This goal is achieved without increasing complication rates and, in our experience, actually improving the quality of clinical care. The cost-effectiveness of clinical pathways may become increasingly important in a managed care-driven environment.
Cranial Nerve Neoplasms↗
Depression after stroke: a review of the evidence base to inform the development of an integrated care pathway. Part 1: Diagnosis, frequency and impact.
BACKGROUND: Depression is a common complication of stroke, leading to increased morbidity and mortality. It can impede the process of rehabilitation, and has been associated with poorer outcomes and increased length of stay in hospital. This systematic review was undertaken as a preliminary step to explore the available evidence on which to base an integrated care pathway (ICP) for the management of post-stroke depression (PSD) in a rehabilitation setting. It is divided into two parts. AIMS AND OBJECTIVES: In part 1 we review the frequency of depression in stroke and its impact on functional recovery. Also the different methods for diagnosis and measurement. METHODS: Data sources comprised a computer-aided search of published studies on depression in stroke and references to literature used in reviews. MAIN FINDINGS: PSD is common and is associated with cognitive, functional and social deficits which potentially limit the outcome from rehabilitation. However, diversity of assessment tools and diagnostic criteria confound assimilation of the available literature. The Beck Depression Inventory (BDI), Hamilton Depression Rating Scale and Zung Self-rating Depression Scale were most commonly used and have demonstrable validity in stroke patients but tend to exclude those with aphasia. Instruments developed specifically to include aphasic patients, such as the Stroke Aphasic Depression Scale, are promising but have yet to be fully evaluated. CONCLUSIONS: Further work is required to adapt and evaluate instruments to measure depression in the context of stroke. Development of an integrated care pathway may help to establish a more consistent approach to assessment and diagnosis of PSD.
Critical Pathways↗
Pathways for evidence-based continence care.
In this article the authors provide an overview of the continence care pathway they designed in 2001. The aim of continence care pathways is to enable nurses to provide evidence-based care to patients in any clinical setting.
Critical Pathways↗
Classifying clinical pathways.
BACKGROUND: Clinical pathways are commonly developed for homogenous patient groups. We were wondering if the traditional patient classification systems could be used for classifying clinical pathways. METHODOLOGY: To examine the utility of patient classification systems for clinical pathways, a sample of 13 clinical pathways was analyzed, involving a total of 412 patients. Three classification systems were tested: International Classification of Diseases, Ninth Revision (ICD9-CM), Clinical Coding System (CCS) data and All-Patient Redefined Diagnosis Related Groups (APR-DRG). RESULTS: Categorization with ICD9-CM and CCS shows rather wide variation. However, when restricting for the principal codes, CCS classification shows an almost homogeneous relationship with clinical pathways. APR-DRG's are already corrected for secondary procedures and are difficult to assess. Categorization with the Risk Of Mortality (ROM) is more homogeneous than with the Severity Of Illness (SOI). CONCLUSION: Patient groups in clinical pathways are rather heterogeneous. When restricting for the principal procedures, the strongest relationship seems to exist between clinical pathways and CCS. Further research is needed to refine this relationship.
Belgium↗
Mouse models of mitochondrial dysfunction and heart failure.
Mitochondria in the adult mammalian heart have a tremendous capacity for oxidative metabolism, and the conversion of energy by these pathways is critical for proper cardiac function. This review describes mouse models relating mitochondrial metabolism to cardiac function through gain- or loss-of-function approaches that manipulate mitochondrial energy transduction or ATP synthetic pathways. Mouse models of mitochondrial defects are relevant to genetic and acquired forms of human cardiomyopathy. Examples include inborn errors in mitochondrial metabolism or end-stage heart failure. Conversely, chronic reliance on energy production via mitochondrial fatty acid oxidation, such as occurs in the diabetic heart, likely leads to maladaptive sequelae including cellular lipotoxicity and mitochondrial dysfunction. Collectively, these model systems have allowed us to begin to dissect the relationship between mitochondrial metabolism and the development of cardiomyopathy and to define the molecular pathways regulating cardiac mitochondrial number and function.
Animals↗
Embryonic neuronal death due to neurotrophin and neurotransmitter deprivation occurs independent of Apaf-1.
Apoptotic protease-activating factor-1 (Apaf-1), dATP, and procaspase-9 form a multimeric complex that triggers programmed cell death through the activation of caspases upon release of cytochrome c from the mitochondria into the cytosol. Although cell death pathways exist that can bypass the requirement for cytochrome c release and caspase activation, several gene knockout studies have shown that the cytochrome c-mediated apoptotic pathway is critical for neural development. Specifically, the number of neuronal progenitor cells is abnormally increased in Apaf-1-, caspase-9-, caspase-3-deficient mice. However, the role of the cytochrome c cell death pathway for apoptosis of postmitotic, differentiated neurons in the developing brain has not been investigated in vivo. In this study we investigated embryonic neuronal cell death caused by trophic factor deprivation or lack of neurotransmitter release by analyzing Apaf-1/tyrosine kinase receptor A (TrkA) and Apaf-1/Munc-18 double mutant mice. Histological analysis of the double mutants' brains (including cell counting and terminal (TdT)-mediated dUTP-biotin nick end labeling (TUNEL) staining) reveals that neuronal cell death caused by these stimuli can proceed independent of Apaf-1. We propose that a switch between apoptotic programs (and their respective proteins) characterizes the transition of a neuronal precursor cell from the progenitor pool to the postmitotic population of differentiated neurons.
Animals↗